Health Matters

The impact of Heart Disease & Diabetes on our community

By Dr.Nandan Koppiker, M.D., M.R.C.P. Senior Associate Director, Pfizer Ltd., and Dr Madhur Rao, M.B.B.S., D.T.M.&. H., Dip.Mgt., MBA. A.C.I.M., Healthcare Solutions Consultant, BUPA

Heart and circulatory disease is the UK's biggest killer. In 2001, cardiovascular disease caused 40% of deaths in the UK, and killed over 245,000 people .

Coronary heart disease, the main form of cardiovascular disease, causes over 120,000 deaths a year in the UK: approximately one in four deaths in men and one in six deaths in women.

Someone has a heart attack every two minutes - 275,000 people each year There are 1.2 million people living in the UK who have had a heart attack

There is considerable variation in mortality from Coronary Heart Disease across the UK. Death rates are higher in Scotland than the South of England, in manual workers than in non-manual workers and in certain ethnic groups.¹

So how do we as a community compare to the general population? South Asians living in the UK (Indians, Bangladeshis, Pakistanis and Sri Lankans), have a higher premature death rate from Coronary Heart Disease than average. The rate is 46% higher for men and 51% higher for women. On the other hand premature death rates for Caribbeans and West Africans are much lower than average - around half the rate found in the general population for men and two-thirds of the rate found in women.

The difference in the death rates between South Asians and the rest of the population is increasing. This is because the death rate is not falling as fast in South Asians as it is in the rest of the population. From 1971 to 1991 the mortality rate for 20-69 year olds for the whole population fell by 29% for men and 17% for women whereas in South Asians it fell by 20% for men and 7% for women.²

Why are we as an ethnic group more prone to develop these risk factors. One of the hypotheses put forward relates to what is called the 'thrifty genotype'. The basic premise of the thrifty gene hypothesis is that certain populations may have genes that determine increased fat storage, which in times of famine represent a survival advantage, but in a modern environment result in obesity and type 2 diabetes(also referred to as Maturity onset diabetes).

Coronary heart disease is not only the single most common cause of death in the UK; it is also very costly, imposing a huge annual burden on UK economy. The costs of healthcare alone are over £1.7 billion a year. However, the majority of the costs fall outside the healthcare and are due to illness and death in those of working age and the economic effects of their families and friends who care for them.

The other big killer is Diabetes. Around 1.4 million people in the UK today have diagnosed diabetes³. At least a million more - 'the missing million' - are thought to have diabetes but do not know it yet.^{4 5 6} The number of people with diabetes is escalating both in the UK and worldwide.^{7 8 9 10}

In 1995, the countries with the largest number of people with diabetes were, and are projected to be in the year 2025, India (19 and 57 million respectively), China (16 and 38 million) and the U.S.A. (14 and 22 million). The greatest increase between 1995 and 2025 is expected to occur in India (195%).¹¹

In India itself there is a difference between rural and urban prevalence of diabetes. A survey in South India found an age adjusted (30-64yrs) prevalence of Type 2 Diabetes Mellitus (also referred to as Maturity onset Diabetes) in rural India of 3.7 and 1.7 for males and females respectively; the same figures for urban India rose to 11.8 and 11.2!

Studies in India estimate that, for a low-income Indian family with an adult with diabetes, as much as 25% of family income may be devoted to diabetes care.

A key factor in the rise in diabetes is the fact that as a nation we are increasingly overweight and are less active - factors that increase the risk of developing diabetes¹². In particular, central body fat - being 'apple shaped' - is strongly linked to insulin resistance, where the body produces but is unable to use insulin properly.

And how does this have an impact on our community? Diabetes is three to five times more common among people of Asian origin and African-Caribbean living in the UK.5 13 In these groups it tends to develop at a younger age and may be due to different underlying mechanisms.¹³

The Joint health Surveys Unit (2001) of England showed that Indians in UK had an overall prevalence of 9.8% in men and 7.2% in women. This increased to 19.2% and 15.3% respectively for those aged above 55yrs.

Even within South Asians there is a difference in the prevalence of Type2 Diabetes Mellitus. Simmons and others carried out a survey in Coventry of 4395 resident Asians, 94% were represented by five communities: Punjabi Sikhs, Punjabi Hindus, Gujerati Moslems, Gujerati Hindus, and Pakistani Moslems. All groups had a higher prevalence of Type 2 diabetes than Europeans. Gujerati Moslems had the highest rate with 16% & 20.4% when compared with the other Asian groups; Punjabi Sikhs 8.9% & 7.5; Pakistani Moslems 9.1% & 10.3%; Gujerati Hindus 8.4% & 8.8%; Punjabi Hindu 11.3% & 11.6% for men and women respectively ¹⁴

Estimates of the precise cost of diabetes vary. However, according to one-study diabetes accounts for some nine per cent of the annual NHS budget. This represents a total of approximately £5.2 billion a year.¹⁵

Numerous studies have shown that people with diabetes are at a substantially increased risk of developing coronary heart disease. So here is the dilemma for us all, that on the one hand Coronary Heart Disease and Diabetes both cause more premature deaths in our community and on the other Diabetes increases the risk of developing Heart Disease. You may wonder then as to why we South Asians have a higher preponderance for these diseases. Some of the reasons identified are:

• South Asian men continue to smoke more than the general population particularly in the Bangladeshi community.
• As a community we eat the least fruit and vegetables of all ethnic groups.
• South Asian men and women are less likely to participate in physical activity than the general population.
• South Asian men and women are more likely than the general population to have central obesity (when fat is centred around the waist), placing an extra strain on the body and heart.
• South Asian men and women are much more likely to have low levels of protective High Density Lipoprotein cholesterol.